Integrity

You’re a medical student on the fourth day of your ob/gyn clerkship, and are invited to observe your first gynecologic surgery. By the time you finish scrubbing in and get to the operating room, the patient is draped and already under general anesthesia. The attending is there and the ob/gyn resident is doing the necessary pre-operative pelvic exam on the patient. The attending asks you if you’ve ever done a pelvic. You reply that you’ve done a couple of them, but never on someone who’s unconscious. The attending says, well this is a great opportunity to get some more practice as you’ll feel less anxious and awkward. She tells you to perform a pelvic exam and press your other hand on her belly to check for abnormalities. While doing this, you start wondering to yourself if the patient has consented to you practicing on her and, if she didn’t, whether she’d be upset. You consider asking the attending this, but worry whether raising this question could affect your evaluation.

Discussion Questions

1. What conflict is the medical student facing?
2. Why might it be tempting in this situation for the medical student to compromise on his or her values?
3. Since the medical student has already started on the pelvic exam, is the opportunity to practice integrity already lost? If not, how can the student maintain integrity?
4. What ideas/values might be in discord with one another within the student if he or she fails to maintain integrity?
5. If the patient finds out later that a pelvic exam was performed on her without her consent, how will the patient-physician relationship be affected?
6. If the student performs the exam without any objection, and the patient never finds out, is any harm really done? If so, what is it?
7. What are some challenges in everyday life that afford opportunities to practice the virtue of integrity?
8. Why do we often see a lack of integrity in the world today? How can we grow the virtue of integrity not just in ourselves, but in those around us?

You are an intern on your internal medicine rotation. It is July, and you are hoping to make a good first impression. Your attending, Dr. Rosales, is a senior attending, who is kind, but detail-oriented. 

On your first day, you get to the hospital 1.5 hour early to give yourself plenty of time to pre-round. You go through all of the overnight events, and you start to go and examine the patients.

At 8am, your team gets together to run the list. You are presenting on Ms. Smith, who is a 64yo woman with heart failure, COPD, DM2, presenting with dyspnea, with concerns for fluid overload. As you are presenting, Dr. Rosales stops you to ask if you checked her JVD. Alas, you had spent a good amount of time with her Ms. Smith this morning, but you had neglected to check a JVD! It suddenly feels like, despite all the time you spent trying to do your best, you left out a simple item that was an important part of the physical exam. You feel tempted to say that you did and that it was elevated, since it should be, but you say you did not. Dr. Rosales explains the importance of checking the JVD.

You get out early because it is your short-call day. You sit down at the hospital library to get some research done for an hour. You are writing a systematic review, and you find another systematic review on a similar topic, organized in a similar way. You start to go through the references and realize, it would be easy just to copy the outline exactly as it is, and to go through most of the same references. You take a pause to wonder if that is ok or not.

That evening, you get dinner with your roommate who works in finance. He shares with you the fact that he has been going out with two different girls on dates, and he is getting more serious with both of them. He asks you what he should do, and when he should tell either of them that he has been doing this, and whether he should just continue as he is until he finds “the one”.

Discussion Questions

1. What are some of your initial reactions to the case?
2. What are the conflicts in integrity in this particular case that the intern is facing?
3. Why are these conflicts particularly challenging in medicine? What are the competing factors?
4. What are some examples of similar cases with regards to integrity that you have come across in the medical setting? What were some of your reflections as you came across those cases?
5. What are your reflections on the final scenario of the dinner discussion with the intern’s friend? How does living virtues outside the hospital affect virtues in the hospital?